Medical Board Review

1. Medical Board Review UROLOGY VIRGILIO G. PETERO, MD Urological and Transplantation Surgery UST Hospital Manila, Philippines

2. Today’ Topic 1. Anatomy and general considerations 2. GU malignancies 3. GU trauma 4. Renal transplantation

3. Anatomy and General • considerations

4. Adrenals • 3-5 cm in dimension • weighs 5 gms each • enclosed w/in the Gerota's • Rt gland- more superior, pyramidal • Lt gland- crescenteric

5. Adrenals • Embryologically distinct from the kidney • Developmental abnormalities of one do not affect the other • Thus, in cases of renal ectopia/agenesis, the AG is not affected (a very common Board Question) 

6. Adrenals • Divided into: A. medulla- receives preganglionic sympathetic input→release of cathecholamines B. cortex: 3 distinct areas: the zona Glomerulosa, z. Fasciculata and z. Reticularis mnemonic: G = Aldosterone F =Costicosteroid R =Testosterone

7. Adrenals • Arterial supply: inf. phrenic , aorta, renal   • Venous drainage: -Rt vein: IVC -Lt vein:Lt renal

8. Kidneys - Primary organ for fluid/electrolyte, acid-base balance - produce renin- vital role in BP control - Erythropoietin- RBC production - Ca2+ metabolism: converts pre-vit D to 1,25-dihydroxyvitamin D (most active form of Vit. D)

9. Kidneys • weighs 150 g in males • 135 g in females • Rt kidney: shorter, wider • effect of liver compression

10. Kidneys • divided into cortex and medulla • Gerota's fascia envelops it on all aspects except inferiorly • From ant. to post. the hilar structures are: VAP (vein, artery, renal pelvis) • Progression of arterial supply: main artery ➙segmental ➙interlobar ➙arcuate ➙interlobular ➙afferent    • The venous system anastomoses freely • The arterial supply does NOT Thus, occlusion of a segmental artery leads to parenchymal infarction but occlusion of a segmental vein does not.   

11. Kidneys Innervation • Sympathetic preganglionic nerves from T8-L1→ travel to the celiac and aorticorenal ganglion • Parasympathetics originate from the vagus N • Vasomotor: sympathetics → vasoconstriction parasympathetics → vasodilation • HOWEVER: functions well even w/o this neurologic control, proof: transplanted kidneys.

12. Ureter • Transitional epithelium • caliber is not uniform • 3 distinct narrowings: (1) uretero-pelvic junction (2) crossing of the iliac vessels (3) the uretero-vesical junction*

13. Ureter Divided into 3 segments: (1) upper- from the renal pelvis to the upper border of the sacrum (2) middle- upper to the lower border of the sacrum (3) lower (distal)- lower border of the sacrum to the bladder

14. Bladder • capacity of approx 500 mL, ovoid shape • Peritoneum covers the superior surface • transitional epithelium • urothelium is 6 cells thick

15. Bladder • Blood supply from int. iliac artery (sup/inf vesical arteries) • The veins coalesce into vesicle plexus→ drain into int. iliac vein • Bulk of lymphatic drainage→ ext.iliac nodes

16. Prostate • weighs 18 g • 3 x4x2 cm (LWH) • traversed by the prostatic urethra • ovoid in shape • apex is continuous with striated urethral sphincter (“rhabdosphincter”, voluntary continence)

17. Prostate • composed of approx 70% glandular elements • 30% fibromuscular stroma • Anatomically divided into 5 zones

18. Prostate The peripheral zone: • makes up the bulk glandular tissue (70%) • 70% prostate CA arise • site of chronic prostatitis • IN CONTRAST: the transitional zone (and periurethral zone) is the site of BPH

19. Prostate BPH w/ moderate to severe LUTS, Tx: 1.TURP “Gold Standard” 2. Medical mgt -α1 adrenergic Blockers - 5 α reductase inhibitors (blocks conversion of testosterone to DHT)

20. Prostate Arterial supply: • From the inferior vesical artery (a branch of the internal iliac artery) Venous drainage: • through the deep dorsal vein (of the penis) Lymphatic drainage: • obturator and int. iliac nodes

21. Vas Deferens • arises from tail of the epididymis • terminal vas is dilated (ampulla), storing spermatozoa. • Trivia: most muscular tubular organ in males -outer longitudinal and inner circular smooth muscle • lined by pseudo-stratified columnar epithelium w/ non-motile stereocilia

22. Seminal Vesicle • lateral outpouching of the vas, approx. 5 cm long, with a capacity of 3-4 mL • Trivia: does NOT store sperm but contributes the largest portion of fluid to the ejaculate • Absence of fructose in the semenalysis would indicate congenital absence of seminal vesicles • lined by columnar epithelium • Blood supply for both V and SV: vesiculo-deferential artery (a branch of the superior vesical artery)

23. Vas and Seminal Vesicle • Drain into the pelvic venous plexus • Lymphatic drainage: to the ext. and int. iliac nodes • Innervation: from the pelvic plexus

24. Penis “The penis does not obey the order of its master, who tries to erect or shrink it at will. Instead, the penis erects freely while its master is asleep. The penis must be said to have its own mind, by any stretch of the imagination.” Leonardo da Vinci

25. Penis Functional anatomy: • 3 cylindrical structures: -paired c. cavernosa -c. spongiosum (w/c houses the urethra) • Skin: highly elastic, w/o appendages (except for the smegma-producing glands at the base of corona)

26. Penis • Buck's fascia: surrounds both cavernosal bodies dorsally and splits to surround the spongiosum ventrally • Bleeding from a tear in the corporal bodies (penile fracture) is usually contained within Buck's fascia, and ecchymosis is limited to the penile shaft i.e. eggplant deformity.

27. Penile fracture eggplant deformity: Buck’s fascia contained the hematoma

28. Penile fracture Butterfly hematoma: if the Bucks fascia is disrupted

29. Penis • Blood supply: common penile artery divides into: (1) The bulbourethral artery (2) The cavernosal artery- center erectile tissue. (3) The dorsal artery of the penis Venous drainage: (1) Deep system- dorsal vein of the penis (2) Superficial system –inguinal and femoral veins.

30. Penis • The dorsal N provide sensory innervation to the penis • Tonic sympathetic tone inhibits erection • Parasympathetic nerves: Ach , NO → cavernosal smooth muscle and arterial relaxation→erection • During erection, the subtunical venules are occluded by being compressed against the nondistensible tunica albuginea • Insufficient venous occlusion, is thought to cause vasculogenic impotence

31. Scrotum • Skin: pigmented, hair bearing, devoid of fat, rich in sebaceous/sweat glands • dartos fascia = Colles', Scarpa's fascia • ext. spermatic fascia = ext. oblique fascia • cremasteric muscle = int. oblique muscle • int. spermatic fascia = transversalis fascia • tunica vaginalis = peritoneum • The testis is fixed by the gubernaculum -If deficient, leaves the testis unfixed (bell-clapper deformity)→ torsion of the cord

32. Scrotum • The ant. wall: supplied by the ext. pudendal vessels and the ilioinguinal and genitofemoral nerves • The post. wall: supplied by the post. scrotal branches of the perineal vessels and nerves • The spermatic cord have a blood supply (cremasteric, vasal, testicular) separate from that of the scrotal wall. • Fournier's gangrene: does not involve these structures, and they (S Cord) may be spared during débridement. • The post. femoral cutaneous nerve (S3) gives a perineal branch to supply the scrotum and perineum.

33. Testes • 4-5 cm long, 3 cm wide, and 2.5 cm deep • Vol.= 30 cc • enclosed in a tough capsule: (1) visceral tunica vaginalis (2) tunica albuginea (3) the tunica vasculosa

34. Testes Flow of spematozoa: seminiferous tubules → tubuli recti → rete testis→ efferent ductules→ the caput → body/ tail epididymis → vas deferens→ ejaculatory duct

35. Testes • Blood supply : (1) testicular artery (2) cremasteric artery (3) branches from the arterial supply of the vas • Testicular biopsy: done at the medial or lateral surface of the upper pole, where the risk of vascular injury least

36. Testes • The testicular veins surround the testicular artery as the pampiniform plexus. • allows countercurrent heat exchange • Testicular temp 3-4 oC lower than core body

37. Testes • The testicular veins may anastomose with the ext. pudendal, cremasteric, and vasal veins • These connections can allow varicoceles to recur after ablative procedures. • The veins join to form a single vein→ inferior vena cava on the Rt and the renal vein on the Lt

38. Testes • Lymphatics drain deep • From Left to Right to the para-aortic and inter-aortocaval nodes

39. 2. GU malignancies

40. Adrenal Carcinoma • rare , poor overall survival of 16%-37% despite treatment • Incidence: 1 per 1.7 million • Accounts for 0.02% of CA and 0.2% of all CA deaths • most are sporadic and unilateral (2- 6% are bil.→ Li-Fraumeni syndrome, MEN type 1) • etiology is unknown • classifed according to the hormones produced • however, nonfunctional tumors may become functional • some may produce multiple hormones

41. Renal Cell Carcinoma • accounts for 2% to 3% of all adult CA • the most lethal of all the urologic CA • >40% die of their cancer (vs. 20% mortality in prostate,bladder CA) • 8.9 new cases per 100,000 per year • male-to-female predominance, 3:2 • disease of elderly (6th ,7th decades of life) • majority are sporadic • only 4% are familial

42. Renal Cell Carcinoma • uncommon in childhood • Although, Wilms' tumor is much more common: - RCC is as common as WT during the 2nd decade of life • stage for stage, children and young adults with RCC respond better to surgical therapy

43. Renal Cell Carcinoma • arise primarily from proximal convoluted tubules • The only environmental risk factor is tobacco exposure (although the relative risks is modest: 1.4- 2.5 vs controls) • All forms of tobacco use have been implicated • risk increases with cumulative dose/pack-years

44. Renal Cell Carcinoma von Hippel–Lindau (vHL) disease: • the familial form RCC • autosomal dominant disorder • major manifestations include: 1. dev. of RCC 2. pheochromocytoma 3. retinal angiomas 4. hemangioblastomas of the CNS

45. Renal Cell Carcinoma von Hippel–Lindau disease: • RCC dev. in 50% of pxs - early age at onset (3rd-5th decade of life) - bilateral and multifocal • With improved management of CNS involvement: - RCC is the most common cause of mortality in vHL pxs

46. Renal Cell Carcinoma Clinical Presentation • sequestered location: asymptomatic, non-palpable until advanced • use of noninvasive imaging: >50% detected incidentally • symptoms: due to local tumor growth, hemorrhage, paraneoplastic syndromes, or metastatic dse • flank pain: due to hemorrhage/clot obstruction • The classic triad of pain, hematuria, and abdominal mass- now rarely found - “too late triad”

47. Renal Cell Carcinoma • Paraneoplastic syndromes: found in 20% of pxs • Previously referred to as the “internist's tumor” bec. of the predominance of systemic rather than local manifestations • Now, a more appropriate name would be the “radiologist's tumor”- frequency of incidental detection • Paraneoplastic phenomena can be a source of major morbidity

48. Renal Cell Carcinoma • Hypercalcemia - most common manifestation of paraneoplastic phenomena (in up to 13% of patients) -production of PTH–like peptides is the most common etiology -could also be due to osteolytic bone mets

49. Renal Cell Carcinoma Stauffer's syndrome • Non-metastatic hepatic dysfxn (3-20%) • Hepatic mets must be excluded • Hepatic function normalizes after nephrectomy in 60%-70% • Persistence/recurrence of hepatic dysfxn - indicates presence of viable tumor, hence, a poor prognosis

50. Renal Cell Carcinoma • Pathologic stage- single most important prognostic factor for RCC • Nodal involvement status worse than caval/atrial thrombus extension (very common board question)